A systematic approach to care that provides a framework for the coordination of medical and nursing interventions.

A

Managed care

B

Critical pathway

C

Acuity Care

D

Intensive care

Question 15

The government reimburses agencies for health care costs incurred by Medicare and Medicaid recipients based on:

A

Documentation by the nurse

B

Appropriate physician progress notes

C

Diagnosis-related groups

D

Minimum data sheets

Question 16

In the SOAPE format, if ever there is a need for changes, where will the REVISIONS (R) be included?

A

REVISIONS belong to another format of documentation

B

REVISIONS are not part of this documentation

C

REVISIONS are noted in the EVALUATION section

D

REVISIONS are noted in the ASSESSMENT section

Question 17

In the SOAPE format, a briefer adaptation of the POMR, where is Intervention (I) included?

A

It is not mentioned in this kind of documentation

B

Included in the notations under PLANNING

C

Included under assessment

D

It belongs to another format

Question 18

This is the main basis for cost reimbursement rates by government plans

A

Critical pathway

B

Minimum data sheet

C

Diagnoses related groups

D

Patient expense documentation

Question 19

Which of the following statements about home health care are true? Select all that apply

A

It provides a narrower scope of people for a wider majority of services.

B

Requires a whole health care team to work closely

C

Does not demand meticulous and thorough documentation

D

Duplication of documentation is difficult to avoid

Question 20

Uses a score that rates each patient by severity of illness.

A

Acuity charting

B

Charting by exception

C

Critical pathway

D

Traditional Charting

Question 21

Which of the following is considered a traditional charting?

A

Narrative

B

Problem Oriented Medical Record

C

SOAPE

D

DARE

Question 22

An irate patient tells a clerk, “I have paid too much every time I came to this clinic for a physical examination. I think my medical records belong to me. I need them now”. What would be the best response.

A

I am required to give you a request form so that I can prove you wanted your records and not just anyone else.

B

Your original health care record belongs to the Physician.

C

One moment, let me make a copy of it immediately. How many do you want?

D

I am so sorry but you really do not have a right to look at your own records.

Question 23

Benefits of a 24-hour patient care records. Select all that apply:

A

Helps eliminate unnecessary record keeping forms

B

Enhances efficiency because flow sheets and checklists are often used.

C

Accommodates a 24-hour period

D

Necessary to maintain a good nursing care plan

Question 24

What does HIPAA mandate health care personnel with regards to patient’s records?

A

Privacy

B

Accessibility

C

Confidentiality

D

Availability

Question 25

One of the benefits of acuity charting is that it provides us with the ability to determine efficient staffing patterns according to the acuity levels of the patients on a particular nursing unit.

A

True

B

False

Question 26

What is the essential difference between PIE and SOAPE formats?

A

PIE is from a nursing process. SOAPE is from a medical model

B

PIE is from a medical model. SOAPE is from a nursing process

C

PIE and SOAPE are both used for charting by exception

D

PIE and SOAPE both emerge from the nursing process

Question 27

Preprinted guidelines used to care for patients with similar health problems.

A

Nursing Care Plan

B

Kardex

C

Common illness index

D

Health intervention reference

Question 28

Which of the following statements about common forms of inadequate documentation should not be included?

A

Not charting correct time when events occurred

B

Failing to record verbal orders or failing to have them signed

C

Documentation only in hand written format even when EMR is mandated

D

Charting actions in advance to save time

E

Documenting incorrect data

Question 29

Patients usually do not have immediate access to their full records. There is one exception. What is it?

A

County hospitals such as Stroger’s Hospital

B

University clinics such as PCCTI Nursing lab

C

Federal Health Care Agencies such as VA hospitals

D

Municipal Health Care Centers such as Oakbrook Health Center

Question 30

Which of the following statements about FOCUS CHARTING is incorrect?

A

Uses the nursing process and the more positive concept of patient needs

B

Focus is sometimes a current patient concern or behavior.

C

Focus is sometimes a significant changes in patient status or behavior or a significant event in the patient’s therapy.

D

Focus can be a medical diagnosis

Question 31

What do Electronic Medical Records require from the health care personnel?

A

Log into the system with a secure password

B

Log into the system with a common password

C

Log into the system with a borrowed password

D

Log into the system with a friend’s password

Question 32

Which of the following practices could lead to malpractice? Select all that apply

A

Charting interventions in advance to save time

B

Documenting incorrect data

C

Not charting the correct time when events took place

D

Deleting incorrect entries and crossing them out with a horizontal line.

E

Not recording verbal orders or not having them signed.

Question 33

Developed by nurses for nurses, it is based on nursing diagnoses and nursing assessment. It also includes, goals, plans for care and specific actions for care implementation and evaluation.

A

Standardized nursing care plans

B

Plans written in nursing notes

C

Narrative planning

D

Kardex or Rand

Question 34

Which of the following statements regarding the DARE format of documentation are correct? Select all that apply

A

Data, action, response and evaluation, education and patient teaching

B

Data is both subjective and objective

C

Action combines planning and implementation

D

You need to use all the DARE steps each time you make notes on a particular focus

E

Response is the same as evaluation and effectiveness

F

Some facilities include education or patient teaching

Question 35

Which of the following formats is included under Charting be exception? Select all that apply.

A

PIE

B

SOAPE

C

SOAPIER

D

APIE

Question 36

There are facilities that require narrative notes for each shift to include a minimum of at least three entries. Legally, care is not given if care is not charted. This is true but it is time consuming and requires excessive detail and a defensive manner in doing so. To solve this issue, what did some hospitals come up with?

A

CBE

B

DOA

C

ABC

D

APIE

Question 37

Charting that is divided into sections or blocks. Emphasis is placed on specific sections, or sheets of information. It also uses graphics and narrative charting.

A

Traditional Chart

B

Problem-oriented medical record

C

Standard form

D

Kardex

Question 38

While doing clinicals, your nurse preceptor had to leave her station immediately due to a code overheard on the public address system. You observed that the computer monitor displayed a patients medical history. This patient was not assigned to your care. What should you do next?

A

Read the medical history for your own education.

B

Turn off the computer as soon as possible

C

Print the document to serve as future reference

D

Call your clinical instructor and ask what to do

Question 38 Explanation:

It is the ethical thing to do to show respect to patient’s confidentiality.

Question 39

Based upon the legal guidelines for documentation, which of the following corrective action is incorrect?

A

Never erase entries or use correction fluid. Never right with a pencil.

B

Do not record “physician made error”.

C

Be certain that entry is factual even when opinions are used

D

While logged into the computer, do not leave terminal unattended even during an emergency.

Question 40

Which of the following statements about Clinical (Critical Pathway) are true? Select all that apply:

A

Allows staff to develop standardized integrated care plans for a projected length of stay for patients of a specific case type.

B

Clinical pathways that delve with cases occur in high volume and are predictable.

C

The clinical pathway replaces other nursing forms such as the nursing care plans

D

Charting by exception is usually the method used for clinical pathways

E

The exact contents and format of these clinical pathways are the same among different institutions.

Question 41

What do you have to fill up when an event transpired is not consistent with routine operation of a health care unit or routine care of a patient or other hospital notification form when patient care delivered is not consistent with facility or national standards of expected care. These events have the potential to cause injury.

A

Injury reports

B

Incident reports

C

Intervention reports

D

Implementation reports

Question 42

What kind of notes are taken when charting by exception? Select all that apply.

A

Additional treatments done or planned treatments withheld

B

Standing orders and physical history

C

New Concerns

D

Changes in patient condition

Question 43

Which of the following are considered the principal sections of a problem-oriented medical record? Select all that apply.

Active, inactive potential and resolved problems that serve as the index for charting documentation

A

Problem assessments

B

Problem List

C

Database

D

Traditional Chart

Once you are finished, click the button below. Any items you have not completed will be marked incorrect.
Get Results

There are 45 questions to complete.

←

List

→

Return

Shaded items are complete.

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

End

Return

You have completed

questions

question

Your score is

Correct

Wrong

Partial-Credit

You have not finished your quiz. If you leave this page, your progress will be lost.

Correct Answer

You Selected

Not Attempted

Final Score on Quiz

Attempted Questions Correct

Attempted Questions Wrong

Questions Not Attempted

Total Questions on Quiz

Question Details

Results

Date

Score

Hint

Time allowed

minutes

seconds

Time used

Answer Choice(s) Selected

Question Text

All done

Need more practice!

Keep trying!

Not bad!

Good work!

Perfect!

Exam Mode

Exam Mode – Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam.

Documentation Practice Exam (EM)*

Please wait while the activity loads. If this activity does not load, try refreshing your browser. Also, this page requires javascript. Please visit using a browser with javascript enabled.

If loading fails, click here to try again

Choose the letter of the correct answer. You have 45 mins to finish this exam. Good luck!

Start

Congratulations - you have completed Documentation Practice Exam (EM)*.
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%%

Your answers are highlighted below.

Question 1

Which of the following statements are true regarding basic rules for documentation. Select all that apply.

A

Use direct quotes for objective assessments

B

If a charting error is made, draw one line through the faulty information

C

Chart only your own care even when someone else calls you for a late entry.

D

Chart after care is provided, as soon as possible, and as often as needed

E

Sign each block of charting with full legal initials and title

Question 1 Explanation:

Use direct quotes for subjective assessment. Sign each block of charting with full initials and title.

Question 2

Active, inactive potential and resolved problems that serve as the index for charting documentation

A

Problem assessments

B

Problem List

C

Database

D

Traditional Chart

Question 3

When does discharge planning ideally begin?

A

During admission

B

After admission

C

Before admission

D

Without admission

Question 4

A system used to consolidate patient orders and care needs in a centralized, concise way.

A

Incident Reports

B

Kardex or Rand System

C

Intervention Guidelines

D

Nursing Care plan

Question 5

Preprinted guidelines used to care for patients with similar health problems.

A

Nursing Care Plan

B

Kardex

C

Common illness index

D

Health intervention reference

Question 6

What do you have to fill up when an event transpired is not consistent with routine operation of a health care unit or routine care of a patient or other hospital notification form when patient care delivered is not consistent with facility or national standards of expected care. These events have the potential to cause injury.

A

Injury reports

B

Incident reports

C

Intervention reports

D

Implementation reports

Question 7

Which of the following statements regarding the DARE format of documentation are correct? Select all that apply

A

Data, action, response and evaluation, education and patient teaching

B

Data is both subjective and objective

C

Action combines planning and implementation

D

You need to use all the DARE steps each time you make notes on a particular focus

E

Response is the same as evaluation and effectiveness

F

Some facilities include education or patient teaching

Question 8

One of the benefits of acuity charting is that it provides us with the ability to determine efficient staffing patterns according to the acuity levels of the patients on a particular nursing unit.

A

True

B

False

Question 9

Which of the following are considered the principal sections of a problem-oriented medical record? Select all that apply.

A

Database

B

Problem list

C

Care plan

D

Physical examination and diagnostic tests

E

Referral form

Question 10

Which of the following should not be considered when filling up an incident report?

A

Do not admit liability or give unnecessary details

B

List date, time and care given to the patient and the name of the Physician notified.

C

Personal assessment and judgment of incident

D

When charting the incident in the patient’s nursing notes, do not mention the incident report.

Question 11

An irate patient tells a clerk, “I have paid too much every time I came to this clinic for a physical examination. I think my medical records belong to me. I need them now”. What would be the best response.

A

I am required to give you a request form so that I can prove you wanted your records and not just anyone else.

B

Your original health care record belongs to the Physician.

C

One moment, let me make a copy of it immediately. How many do you want?

D

I am so sorry but you really do not have a right to look at your own records.

Question 12

Which of the following is a typical section of a traditional chart? Select all that apply

A

Admission sheet and physician’s orders

B

Progress notes and nurse’s admission information

C

History and Physical Examination Data

D

Medical Administration Record

E

Care plan and nurse’s notes

Question 13

The government reimburses agencies for health care costs incurred by Medicare and Medicaid recipients based on:

A

Documentation by the nurse

B

Appropriate physician progress notes

C

Diagnosis-related groups

D

Minimum data sheets

Question 14

Which of the following are basic purposes for an accurate and complete written patient records? Select all that apply

A

Sometimes used by government agencies to evaluate patient care

B

It is a permanent record for accountability

C

It is a legal record of care

D

They are perfect sources for business and marketing

E

Can be used for research, teaching and data collection

Question 15

Based upon the legal guidelines for documentation, which of the following corrective action is incorrect?

A

Never erase entries or use correction fluid. Never right with a pencil.

B

Do not record “physician made error”.

C

Be certain that entry is factual even when opinions are used

D

While logged into the computer, do not leave terminal unattended even during an emergency.

Question 16

There are facilities that require narrative notes for each shift to include a minimum of at least three entries. Legally, care is not given if care is not charted. This is true but it is time consuming and requires excessive detail and a defensive manner in doing so. To solve this issue, what did some hospitals come up with?

A

CBE

B

DOA

C

ABC

D

APIE

Question 17

Which of the following statements about home health care are true? Select all that apply

A

It provides a narrower scope of people for a wider majority of services.

B

Requires a whole health care team to work closely

C

Does not demand meticulous and thorough documentation

D

Duplication of documentation is difficult to avoid

Question 18

In the SOAPE format, if ever there is a need for changes, where will the REVISIONS (R) be included?

A

REVISIONS belong to another format of documentation

B

REVISIONS are not part of this documentation

C

REVISIONS are noted in the EVALUATION section

D

REVISIONS are noted in the ASSESSMENT section

Question 19

Which of the following are considered examples of record keeping forms? Select all that apply.

A

Kardex or Rand

B

Nursing Care Plan

C

Incident Reports

D

24-hour patient care and acuity charting

E

Discharge summary

Question 20

When is it unnecessary to chart a narrative note? Select all that apply.

A

Each time you give a medication

B

Each time a bath is given

C

Each time a decubitus ulcer changes in appearance

D

Each time you assess vital signs

Question 21

Required by the Omnibus Budget Reconciliation Act primarily for Long Term Care facilities

A

MDS

B

DRG

C

BCG

D

NCLEX

Question 22

Which of the following practices could lead to malpractice? Select all that apply

A

Charting interventions in advance to save time

B

Documenting incorrect data

C

Not charting the correct time when events took place

D

Deleting incorrect entries and crossing them out with a horizontal line.

E

Not recording verbal orders or not having them signed.

Question 23

Which of the following statements about common forms of inadequate documentation should not be included?

A

Not charting correct time when events occurred

B

Failing to record verbal orders or failing to have them signed

C

Documentation only in hand written format even when EMR is mandated

D

Charting actions in advance to save time

E

Documenting incorrect data

Question 24

Charting that is divided into sections or blocks. Emphasis is placed on specific sections, or sheets of information. It also uses graphics and narrative charting.

A

Traditional Chart

B

Problem-oriented medical record

C

Standard form

D

Kardex

Question 25

Developed by nurses for nurses, it is based on nursing diagnoses and nursing assessment. It also includes, goals, plans for care and specific actions for care implementation and evaluation.

A

Standardized nursing care plans

B

Plans written in nursing notes

C

Narrative planning

D

Kardex or Rand

Question 26

This is the main basis for cost reimbursement rates by government plans

Involves recording the interventions carried out to meet the patient’s needs.

B

Done in a proper way, it reflect the nursing process.

C

Necessary to prove that nursing work was done.

D

Nursing documentation can be accepted in both verbal and written form

Question 29

Uses a score that rates each patient by severity of illness.

A

Acuity charting

B

Charting by exception

C

Critical pathway

D

Traditional Charting

Question 30

While doing clinicals, your nurse preceptor had to leave her station immediately due to a code overheard on the public address system. You observed that the computer monitor displayed a patients medical history. This patient was not assigned to your care. What should you do next?

A

Read the medical history for your own education.

B

Turn off the computer as soon as possible

C

Print the document to serve as future reference

D

Call your clinical instructor and ask what to do

Question 30 Explanation:

It is the ethical thing to do to show respect to patient’s confidentiality.

Question 31

What is the difference between Traditional and Problem Oriented medical Record charting?

14. Which of the following are considered the principal sections of a problem-oriented medical record? Select all that apply.

Database

Problem list

Care plan

Physical examination and diagnostic tests

Referral form

15. Active, inactive potential and resolved problems that serve as the index for charting documentation

Problem assessments

Problem List

Database

Traditional Chart

16. In the SOAPE format, a briefer adaptation of the POMR, where is Intervention (I) included?

It is not mentioned in this kind of documentation

Included in the notations under PLANNING

Included under assessment

It belongs to another format

17. In the SOAPE format, if ever there is a need for changes, where will the REVISIONS (R) be included?

REVISIONS belong to another format of documentation

REVISIONS are not part of this documentation

REVISIONS are noted in the EVALUATION section

REVISIONS are noted in the ASSESSMENT section

18. Which of the following statements about FOCUS CHARTING is incorrect?

Uses the nursing process and the more positive concept of patient needs

Focus is sometimes a current patient concern or behavior.

Focus is sometimes a significant changes in patient status or behavior or a significant event in the patient’s therapy.

Focus can be a medical diagnosis

19. Which of the following statements regarding the DARE format of documentation are correct? Select all that apply

Data, action, response and evaluation, education and patient teaching

Data is both subjective and objective

Action combines planning and implementation

You need to use all the DARE steps each time you make notes on a particular focus

Response is the same as evaluation and effectiveness

Some facilities include education or patient teaching

20. There are facilities that require narrative notes for each shift to include a minimum of at least three entries. Legally, care is not given if care is not charted. This is true but it is time consuming and requires excessive detail and a defensive manner in doing so. To solve this issue, what did some hospitals come up with?

CBE

DOA

ABC

APIE

21. Which of the following formats is included under Charting be exception? Select all that apply.

PIE

SOAPE

SOAPIER

APIE

22. What is the essential difference between PIE and SOAPE formats?

PIE is from a nursing process. SOAPE is from a medical model

PIE is from a medical model. SOAPE is from a nursing process

PIE and SOAPE are both used for charting by exception

PIE and SOAPE both emerge from the nursing process

23. What kind of notes are taken when charting by exception? Select all that apply.

Additional treatments done or planned treatments withheld

Standing orders and physical history

New Concerns

Changes in patient condition

24. In charting by exception, what happens after the patient’s problem is resolved?

It needs to be a part of the SOAPE documentation

It needs to be explained to the next shift

It is no longer covered by daily documentation

It needs to be transferred to a permanent record

25. Which of the following are considered examples of record keeping forms? Select all that apply.

Kardex or Rand

Nursing Care Plan

Incident Reports

24-hour patient care and acuity charting

Discharge summary

26. A system used to consolidate patient orders and care needs in a centralized, concise way.

Incident Reports

Kardex or Rand System

Intervention Guidelines

Nursing Care plan

27. Preprinted guidelines used to care for patients with similar health problems.

Nursing Care Plan

Kardex

Common illness index

Health intervention reference

28. Developed by nurses for nurses, it is based on nursing diagnoses and nursing assessment. It also includes, goals, plans for care and specific actions for care implementation and evaluation

Standardized nursing care plans

Plans written in nursing notes

Narrative planning

Kardex or Rand

29. What do you have to fill up when an event transpired is not consistent with routine operation of a health care unit or routine care of a patient or other hospital notification form when patient care delivered is not consistent with facility or national standards of expected care. These events have the potential to cause injury.

Injury reports

Incident reports

Intervention reports

Implementation reports

30. Which of the following should not be considered when filling up an incident report?

Do not admit liability or give unnecessary details

List date, time and care given to the patient and the name of the Physician notified.

Personal assessment and judgment of incident

When charting the incident in the patient’s nursing notes, do not mention the incident report.

31. Benefits of a 24-hour patient care records. Select all that apply:

Helps eliminate unnecessary record keeping forms

Enhances efficiency because flow sheets and checklists are often used.

Accommodates a 24-hour period

Necessary to maintain a good nursing care plan

32. Uses a score that rates each patient by severity of illness.

Acuity charting

Charting by exception

Critical pathway

Traditional Charting

33. One of the benefits of acuity charting is that it provides us with the ability to determine efficient staffing patterns according to the acuity levels of the patients on a particular nursing unit.

True

False

34. When does discharge planning ideally begin?

During admission

After admission

Before admission

Without admission

35. A systematic approach to care that provides a framework for the coordination of medical and nursing interventions.

Managed care

Critical pathway

Acuity Care

Intensive care

36. Which of the following statements about Clinical (Critical Pathway) are true? Select all that apply:

Allows staff to develop standardized integrated care plans for a projected length of stay for patients of a specific case type.

Clinical pathways that delve with cases occur in high volume and are predictable.

The clinical pathway replaces other nursing forms such as the nursing care plans

Charting by exception is usually the method used for clinical pathways

The exact contents and format of these clinical pathways are the same among different institutions.

37. Which of the following statements about home health care are true? Select all that apply

It provides a narrower scope of people for a wider majority of services.

Requires a whole health care team to work closely

Does not demand meticulous and thorough documentation

Duplication of documentation is difficult to avoid

38. Required by the Omnibus Budget Reconciliation Act primarily for Long Term Care facilities

MDS

DRG

BCG

NCLEX

39. An irate patient tells a clerk, “I have paid too much every time I came to this clinic for a physical examination. I think my medical records belong to me. I need them now”. What would be the best response.

I am required to give you a request form so that I can prove you wanted your records and not just anyone else.

Your original health care record belongs to the Physician.

One moment, let me make a copy of it immediately. How many do you want?

I am so sorry but you really do not have a right to look at your own records.

40. Patients usually do not have immediate access to their full records. There is one exception. What is it?

County hospitals such as Stroger’s Hospital

University clinics such as PCCTI Nursing lab

Federal Health Care Agencies such as VA hospitals

Municipal Health Care Centers such as Oakbrook Health Center

41. What does HIPAA mandate health care personnel with regards to patient’s records?

Privacy

Accessibility

Confidentiality

Availability

42. What do Electronic Medical Records require from the health care personnel?

Log into the system with a secure password

Log into the system with a common password

Log into the system with a borrowed password

Log into the system with a friend’s password

43. The government reimburses agencies for health care costs incurred by Medicare and Medicaid recipients based on:

Documentation by the nurse

Appropriate physician progress notes

Diagnosis-related groups

Minimum data sheets

44. While doing clinicals, your nurse preceptor had to leave her station immediately due to a code overheard on the public address system. You observed that the computer monitor displayed a patients medical history. This patient was not assigned to your care. What should you do next?

Read the medical history for your own education.

Turn off the computer as soon as possible

Print the document to serve as future reference

Call your clinical instructor and ask what to do

45. When is it unnecessary to chart a narrative note? Select all that apply.

Each time you give a medication

Each time a bath is given

Each time a decubitus ulcer changes in appearance

Each time you assess vital signs

Answers

1. C. Data entry

2. D. Nursing documentation can be accepted in both verbal and written form.

3. A,B,C,E.

4. C. Diagnoses related groups

5. B,C,D. Use direct quotes for subjective assessment. Sign each block of charting with full initials and title.

6. C. Be certain that entry is factual even when opinions are used.

7. C. Documentation only in hand written format even when EMR is mandated

8. B. Narrative

9. A,B,C, E.

10. A. Traditional Chart

11. A,B,D,E

12. A. Narrative

13. A. Traditional uses an abbreviated story form. POMR uses an outline form

14. A,B,C,D

15. B. Problem List

16. B. Included in the notations under PLANNING

17. C. REVISIONS are noted in the EVALUATION section

18. D. Focus can be a medical diagnosis

19. A,B,C,E,F

20. A. CBE

21. A,D

22. A. PIE is from a nursing process. SOAPE is from a medical model

23. A,C,D

24. C. It is no longer covered by daily documentation

25. A,B,C,D,E

26. B. Kardex or Rand System

27. A. Nursing Care Plan

28. A. Standardized nursing care plans

29. B. Incident reports

30. C. Personal assessment and judgment of incident

31. A,B,C.

32. A. Acuity charting

33. A. True

34. A. During admission

35. A. Managed care

36. A,B,C,D

37. A,B,D

38. A. MDS

39. A. I am required to give you a request form so that I can prove you wanted your records and not just anyone else.

40. C. Federal Health Care Agencies such as VA hospitals

41. C. Confidentiality

42. A. Log into the system with a secure password

43. C. Diagnosis-related groups

44. B. Turn off the computer as soon as possible. It is the ethical thing to do to show respect to patient’s confidentiality.